05080124 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION.
BUILDING ADDRESS: PERMIT NO.0 5 0 8 0124
20745 STEVENS CREEK BLVD
NEWS NAME: PERMIT ISSUE DATE
TARGET CORP 02/03/2006
NE: SANITARY NO. CONTROL NO.
ARCHITECDENGTNEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 I�
u00 LICENSED CONTRACTOR'S DECLARATION
�u C 1 hereby affirm that 1 am licensed under provisions,of Chapter 9(commencing Job Description
^=NmmU wiNScctionndafecDiviaion3afNCBusincvvndPr�rc�i�nOde.andmyueen:cia TI-ELECT/HVAC/PLUMB/ELECT/MECH
in full Tone and cRca
7vvj? License as Lic.N
;—o Date Conlracwr - FOOD SERVICE/STRUCTURAL
t� ARCNTECTSDECLA ATION TEMP PERMIT #06010038 (EXPIRE 02/05/06)
i 1 understand my pUru Mall he used as public recordsI.Q
Z i)� Licensed Profesrional
SOWNER,RUILDER DECLARATION
y I hemhy affirm that I am exempt from the Contractor's License Law for the
HO following mason.(Smism 7031.5,Business and Profusions Coda:My city or county
K$ff which requires a permit to construct.slur,improve,demolish,or repair any structure
zot
prior to is,issuance.also requires the applicant for such permit O file a signed suonent
�< ,hatkislicensed pursuant onNcpmvisiossafthe Comrxmr'sU..Law(Chapter 9 Sq. Ft. Floor Area Valuation
zt• (commencing with Section 7")of Division 3ofthe Business and PmfessimnsCode)or $5200000
My
59
— that he is exempt therefrom and the,basis for the alleged examption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(SMP Y YP
❑I.nownerof Ne property,or myemploycu with wagesu their sale compensation,
will do the work,and to structure is not intended oroffered forme(Sec.7066,Business
and Profusions Cade:The Canuacori Ligase Taw doss out apply to an Ounces of Requirgil-TIP
propcnywho builds arimprovss thereon,and who does inch worts himselfor through his
own employes,,provided that such improvements are not intended oroRered formic.IL a
however,the building or improvement is sold within one yesr of completion,Ne owner
builder will haus use,burden of moving Nat M did not build or improve for purpose of G
0 1. s� 7 !�
❑1.as t the project of the proporty,am 71)4.B eulus and contracting with licensed tomato, o
masse La the u (Sec.JB66,Business and property
who Wilds
Cade:)The Caouacor's Lid (I/ t7gt [�Jryrl s nq�
come law dos not apply a an owner of poperty.who builds ar antovu Contras and
who contracts for such projects with a conwnor(q licensed pursuant m the Contractor's {{11
0
License
❑Ions ucmpt undo Sea ,B&PCfar Nis mason
nor Data
WORKERS COMPENSATION DECLARATION
I hereby affirm uWnder pmty or perjury one of do following declarations
I ban and will maintain a Certificate of ConsrnNoself-insum for y<
Worr's Compen.
moon,u provided fm by Seeuon 37M of the tabor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workeri Compensation Insurance,as required by Section
3700 of the labor Code.for the performance of the work for which Nmit is peris issued.
My Worker's Compx:asa0 nsur
IanU
ce niv end Polity rt
number a :
Carrier:74j91 H AME14C*WyNa.:U/G31 G5' Z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mais section need not he completed if the permit is forms,hundroddolla a($I00)
IusJ
1 confry that in the pedmmuee of the work for which this permit is issued.1 Mall not
employ any person in any manner so as to become subject to de Workers Compensation
Laws of Califaois.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenifiute of Exemption,you Mould
become subject to the Worker's Compensation previsions of Inc labor Code,you must
.J O fmMwi0 comply with such provisions or Nis permit Mall he deemed reversed.
z"' CONSTRUCTION LENDING AGENCY
[•+4 l hereby aRrm that them is a construction lending agency,for the performance of
p$> the work for which Nis permit u issued(Sec.3097,Civ,C.)
ALender's Name
D z finder's Address
U Q 1 certify that 1 have read this application and soon that the above boreco oom is
Ip.f MMOL 1 agree in comply with all city and comely Ordinances and sun laws relating in
�fJ Wilding cmtsuoction,and hereby auNorim opresenmivu of this city to enter upon the
r W Mov-mentioacd popery for inspection purposes.
f3. (we)agree to rave indemnity arod keep harmless the City of Cupertino a"Oned,
ULaliiities,judgmenu,costs and expenses which may in any way ancon C
n against said
Z
n consequence of the granting of this Permit. 7
APPLICANT UND ISTANDS AND WILL COMPLY WITH ALL NON-POINr
T Issued by: Date !i r7
'J G
SOURCE s4te�
REGU TONS. a I"
signenra ar ppbcanuCCon—�r —T o.in Re-roofs f'
HAZARDI'US MATERIALS DISCLOSURE Type of Roof
Will the applicant Or forum building occupant am atheistic hvzrdm n matins]
u OeOn ed by the Cupertin)? o Municipal Code,Chapter 9.12,and the Hcelth and Safety
J0.Section 25532(a /
Dyes rgSNu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7�6::
hazardous air contaminants as declined by the Bay Area Air Quality Management all new materials for inspection.
ict?
❑Yu V(Nu
than maJ the hvaNtms materials mquimmenu under Chapter Q95 of @c Califon
ralth Sk Safety Code,Seeuoas 25505.25533 and 25536.1 undersand limiftM building
not core`1 have a¢nam.Nat it u my responsibility u notify Nc oceupam of the
mcnu mustbc etprio issuanccmfaCc.ucanofac y Signature ofApplicant Date
or authomsd apcnl Date All roof coverings to be Class."B"or better